Ohio Department of Aging

Nominee's name:
Daytime phone:
Street address:
City, state, ZIP:
County of residence: -- Choose One -- Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
Birth Date:

Family contact (for verification and coordination):
Phone:
Street address:
City, state, ZIP:
County of residence: -- Choose One -- Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
Relationship to candidate:

Nominee's major field(s) of endeavor (hold down CTRL key to select more than one): Arts Athletics Business/industry Community service/volunteerism Education Health Literature Politics Other

Is the nominee to be honored for service after age 60? YES NO

Is the nominee to be honored for lifetime service/achievement? YES NO

Is a photo of the nominee available? (Do not send originals) YES NO

Is supporting documentation available? (Do not send originals) YES NO

Describe the service or achievement(s) for which the candidate should be recognized:

List the length of involvement in the major field(s) of endeavor and describe the nominee's impact on the field(s):

Describe how nominee presents a positive image of aging:

Describe unusual circumstances/difficulties that nominee overcame:

List awards, recognitions and honors that the candidate has received:

List boards, commissions and organizations in which the candidate was or is a member and any offices held. (Indicate if a resume is available)

Name:
Organization (optional):
Street address:
City, state, ZIP:
County of residence: -- Choose One -- Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
Phone:
E-mail (optional):

By clicking the submit button below, you certify that the information above is true and accurate. Nomination forms must be received by November 1. All nominations received after this date will be held for the following year. Please refer to our Privacy Statement for details about information sent electronically.